A 7 year old girl with sero-negative polyarticular juvenile idiopathic arthritis (JIA) has recently commenced weekly methotrexate (MTX). Within six months she develops painful apthous ulcerations, alopecia, and generalised gastrointestinal upset. Her hepatic transaminases (AST/ALT) are now raised. Her parents are obviously distressed and have read on the internet about the role of folate supplementation in counteracting the adverse side effects of MTX. They have also read however, that this beneficial effect may be at the expense of the efficacy of MTX. They ask you, the prescribing physician, if this additional medication is warranted, and if so in what form?

Structured clinical question

In children with juvenile idiopathic arthritis [patient], does folate supplementation [intervention] counteract the adverse side effects and/or effect the efficacy of methotrexate [outcome]?

Search strategy and outcome

Secondary source: Cochrane Library, nil relevant.

Primary source: Medline via Pubmed: search terms “methotrexate” or “methotrexate efficacy” or “ methotrexate toxicity”, or “ methotrexate side effects” and “juvenile arthritis” and “folinic acid supplementation” or “folic acid supplementation”. Limits: all child: 0–18 years.

Search result: nine papers identified, three papers relevant. See table …